Fla. mom awarded $10M in ambulance birth lawsuit

[JPINFV]

For goodness sakes JP! Do you not know how to search for neonatal statistics? The stats quotes at 50% came from JEMS. It just took a few quick checks to see where he pulled that number from on the internet. I never made any direct statement as to where he got that information because JEMS was not part of the trial. Just look at the reputable neonatal websites and you can read all about neonatal stats. I also take NRP which is full of fascinating stats in the reference section that makes taking the course over and over again worthwhile as they are being updated as medicine evolves.

I honestly don't have the time right now to pour over statistics for your arguments. If you have easy access to the statistics, then just post them. You brought them to the table, it's your job to provide a citation. So until you decide to post the source, this is going to be decisively a [citation needed].

Like ACLS or any cert class on has to realize its limitations. However, if you do not put forth ANY effort to acquire at least the bare minimum of training, how can you even justify being capable of handling a neonatal transport. This baby did not get intubated during resuscitation. If a company wanted their employees to do neonatal IFTs, they should have seen that they got the training by whatever means. Bashing NRP still does not make it right. As least the NRP would show they put forth some effort if they can not come up with any other proof of competence. Also, when you do get the chance to take NRP you will find they make the same disclaimer as any other cert makes like ACLS or PALS. It does NOT replace proper education and training. If they had actually taken the NRP, they might have known this and realized their limitations.

If I'm bashing NRP, then the AAP is bashing its own program. Of course, everything stated here could just as easily be stated about the hospital. Maybe the hospital realized their limitations in caring for this patient?

If you advocate for a system that continues to fail and just want to make excuses, other ambulance personnel will be put into the same position. Realize the mistakes and move on with proper education and communication with your medical director.

There's a big difference between advocating for a particular system and realizing a "damned if you do, damned if you don't" situation.

EMT-Bs deliver babies. Mothers deliver their own babies. However, the mother is just part of the equation and in no way is a preemie self sufficient unless someone can provide the minimum comfort. I am repeating myself but EDs in the U.S. have a pedi/neo code cart, warmer, infant ventilator and a variety of staff that can offer some level of expertise in their own specialty be it lab, nursing or respiratory.

Stopped reading here as ERDoc has already posted a refute to this. Not every hospital has those devices. Strangely enough.

So, why do you feel it is safer for the baby, mother, EMS providers and the public to have an ambulance running L&S for almost 70 miles without someone who can intubate a baby to provide oxygen and provide adequate warmth? If the hospital stuck by a decision not to transport with the local ambulance because they were calling specialty teams, there is still a chance they would have been sued but by showing the ambulance was not capable of providing a safe transport alternative, their damages would have been less. The ambulance had good reasons not to accept.

I'll ask again, since apparently you didn't see it. Is neonatal intubations within the scope of practice for paramedics in Florida? If it is, then the baby was with someone who should have been able to intubate the patient. Are you going to expect a little miniskills exam in the hospital prior to every transport? What would you do if you were on a CCT and the first thing the physician said to you was, "Intubate this manikin"? Furthermore, if a neonatal recovery team arrived, then they aren't going to be transporting anyone until the baby is born (which, in reality, could take a while. Remember, we're seeing this with 20/20 hind sight) because I highly doubt that they're going to be able to transport the mother in the same ambulance as the isolette. There simply isn't enough room for the isolette and a stretcher in the same vehicle. So if it had taken 2 hours instead of 15 minutes, then the team would be standing around for 2 hours in the ER. Again, damned if they do, damned if they don't.

Arrogance should not replace education and ignorance is not a good defense. The hospitals and physicians knew where they screwed up. This ambulance service should have realized their limitations and had their medical director be more proactive for them to prevent them from being placed in this situation. It is not like there were no other transport teams and those with access to helicopters that could have at least provided someone who could establish a neonatal airway. There is also a good chance if that mother delivered in that ED that someone would have been able to do ETI on a neonate and under a warmer. And again, if an advanced team felt it was unsafe to move the patient, they would have remained until stable or additional resources could arrive. Any other health care professional would be held accountable and if they accepted something they were not qualified for, they would have to answer for it and why they made the decision. Why should EMS be the exception?

That's a good idea... Let's deliver the baby in a helicopter at 5,000 feet. Also, (I'll ask it again in this thread, in case you missed it), if paramedics are allowed to do neonatal intubations, then the paramedic supposedly has the ability to establish an airway. If the mother is not progressing or has contractions pharmaceutical suppressed, how long do you wait until you transport?

So JP, when you become a doctor, are you going to pressure EMT-Bs and Paramedics to accept transports that put them outside of limitations? Are you still going to rely on L&S and a real fast ambulance ride to get critical patients from point A to point B?

It's all situational dependent. As I've said earlier, the trauma patient at the little community hospital may require procedures outside the scope of the transporting crew, however you aren't going to just let the trauma patient sit at the local community hospital with no trauma services all day long. Similarly, and since we're talking generalities, I'm not going to expect the hospital to send one of the 2 nurses in the ER or the only physician available for a 2 hour ride when there is no other options. Sometimes both ends of the stick are dirty. Additionally, you use the resources you have available, not the resources you ideally want.

Do you also not have the ability as an EMT-B to call for ALS? Hasn't this been discussed over and over on these forums? Again, there is also a difference between some adult airways and that of a neonate. The adult can be managed by BVM. However, the 25 week neonate that is coding requires an ETT. You may not have enough education in this area to understand this which is also what happened in this situation.

To properly compare this, if an EMT-B crew assesses a patient as outside of their ability, they should go to the nursing station, tell them to call 911, and then leave. That is what is being advocated in this case and I guarantee you that any EMT-B who does this (just ups and leaves telling the SNF "no") will be hung.

This comment by JP is probably the most misunderstood by many and it is frightening. I believe I may have also mentioned it earlier as well and am again repeating myself.

Because it is allowed in your scope of practice does not necessary mean you have been properly trained or educated to do so. RSI might be allowed by your state but does that mean every Paramedic is competent to do RSI. Just having it as part of your state scope does not make you competent. Some Paramedics many never do or even see a live intubation on any age before they graduate from Paramedic school. The Paramedic should know their limitations. One should take professional responsibility for skills and knowledge expected of you. It would also be in the best interest of the patient to inform those trusting you of your limitations will not enable the physician to make a more informed decision about the proper transport.

If a paramedic is allowed to do something then they should be trained and educated to do it. Period. Otherwise remove it from the scope of practice. The transferring physician doesn't know what each and every paramedic's competency level is and has no real method of checking said competency. Furthermore, if the physician can't be sure what part of the scope of practice any crew is comfortable with or not comfortable with, then why even have those providers?

[chbare]

Perhaps a fair question to ask is, with the avaliable information would you as the paramedic have transported this patient? Personally, I am not going to transport a 25 weeker having contractions every four minutes regardless of station, dilation, or effacement. Even with the ability to intubate, I have no isolette, no surfactant, no ventilator able to manage such a small patient and no other high risk neonatal resources.

JPINFV, I understand the damned if you do or do not argument; however, I personally would not have transported this patient with the information we have available.

Take care,

chbare.

[VentMedic]

I honestly don't have the time right now to pour over statistics for your arguments. If you have easy access to the statistics, then just post them. You brought them to the table, it's your job to provide a citation. So until you decide to post the source, this is going to be decisively a [citation needed].

Here's an idea for both you an ERdoc...talk to a neonatalogist. See if a 25 week baby is viable.

If I'm bashing NRP, then the AAP is bashing its own program. Of course, everything stated here could just as easily be stated about the hospital.

Did you not read what I stated about the NRP which is also stated in the course?

Maybe the hospital realized their limitations in caring for this patient?

The hospital knew they could not keep a 25 week baby. However, they could have kept the mother if she delivered.

There's a big difference between advocating for a particular system and realizing a "damned if you do, damned if you don't" situation.

If this was an area where there were no transport options for hundreds of miles...maybe. But if that is the case you damned well better have some way of keeping a neonate alive. Just, "oh well, if they live, they live" is not acceptable.

Stopped reading here as ERDoc has already posted a refute to this. Not every hospital has those devices. Strangely enough.

Please tell me which hospital in California does NOT have a pedi code cart in the ED or within easy access to the ED. Do they have a big sign at the ED entrance stating "Absolutely NO children allowed"? There would be a few agencies that would love to have this information. If you don't want to state it on the forum you can PM me and I will see that someone in that hospital knows the importance of having a pedi cart. Even in purely adult hospitals they must have resuscitation equipment available for all ages.

I'll ask again, since apparently you didn't see it. Is neonatal intubations within the scope of practice for paramedics in Florida? If it is, then the baby was with someone who should have been able to intubate the patient.

Again you fail to see the difference between what is your "scope of practice" and what you are able to do. Just because it states "intubate" in a statute does not mean YOU can do the skill. Haven't we already seen enough of this with ETI in the adult world or in pedi in CA to where ETI is no longer part of some agencies' scope. ECMO is also within an RN's and RRT's scope of practice but that doesn't mean anyone can do it or can do Mobile ECMO if asked out of the blue.

However, in Florida a Paramedic can intubate a baby. Why did this Paramedic fail to do so on this transport? The statute clearly states intubation is allowed. Right there you have just presented an argument to hang that Paramedic. If this person holds a Paramedic patch they should automatically be proficient at intubating a 25 week baby. How many Paramedics have even seen a 25 week baby in person? Paramedic school does not prepare you for everything and some things are left up to your company especially if they are telling you to transport these patients.

Are you going to expect a little miniskills exam in the hospital prior to every transport? What would you do if you were on a CCT and the first thing the physician said to you was, "Intubate this manikin"? Furthermore, if a neonatal recovery team arrived, then they aren't going to be transporting anyone until the baby is born (which, in reality, could take a while. Remember, we're seeing this with 20/20 hind sight) because I highly doubt that they're going to be able to transport the mother in the same ambulance as the isolette. There simply isn't enough room for the isolette and a stretcher in the same vehicle. So if it had taken 2 hours instead of 15 minutes, then the team would be standing around for 2 hours in the ER. Again, damned if they do, damned if they don't.

The transferring doctor has a right to know if you have ever worked with a certain med, a piece of equipment, special ETT or when you last intubated a pediatric. No I am not seeing this hindsight since I have participated in calls like this. There are other ways to keep a baby warm without the isolete such as a portable heat pad. There are some with the chemical gel and other that can run off the ambulance's electricity. We keep a couple of packs just incase of equipment failure although 70 miles might be a stretch even in Florida's heat. Specialty teams are also patient people. If the Maternal High Risk team was dispatched first, they could evaluate when the neo team could arrive if it was not safe to transport. Again, EMT(P)s are always in a hurry which makes them not a wise choice for specialty transport. Speed is not the answer for all patients. A neo/pedi team may spend several hours at the hospital stabilizing before transport.

That's a good idea... Let's deliver the baby in a helicopter at 5,000 feet. Also, (I'll ask it again in this thread, in case you missed it), if paramedics are allowed to do neonatal intubations, then the paramedic supposedly has the ability to establish an airway. If the mother is not progressing or has contractions pharmaceutical suppressed, how long do you wait until you transport?

Read my above posts and all the previous ones. ETI is still just one part. The baby will die from exposure if temperature is not maintained. There are also other factors that go with S.T.A.B.L.E.

It's all situational dependent. As I've said earlier, the trauma patient at the little community hospital may require procedures outside the scope of the transporting crew, however you aren't going to just let the trauma patient sit at the local community hospital with no trauma services all day long. Similarly, and since we're talking generalities, I'm not going to expect the hospital to send one of the 2 nurses in the ER or the only physician available for a 2 hour ride when there is no other options. Sometimes both ends of the stick are dirty. Additionally, you use the resources you have available, not the resources you ideally want.

It's done in the U.S. everyday. Some places have good Flight and ground programs. I would much rather have a patient stablized in a hospital rather than running real fast down the highway in an ambulance with a crew with limited abilities. Ever hear about the effectiveness of CPR in a moving ambulance?

To properly compare this, if an EMT-B crew assesses a patient as outside of their ability, they should go to the nursing station, tell them to call 911, and then leave. That is what is being advocated in this case and I guarantee you that any EMT-B who does this (just ups and leaves telling the SNF "no") will be hung.

As I already stated, as an EMT-B you do have the opportunity to call for ALS or 911 yourself. You don't need a nurse to dial the phone for you.

However, this call should never have gotten as far as it did with all the known factors involved. The ambulance was called. They know what the call was about and accepted. They were not called by 911 to an "unknown medical". Hospitals are turned down by ambulances everyday for a patient being out of what their protocols cover. There is a good chance the ambulance service you work for has turned down a few calls that you as an EMT should not be on.

And again, I will repeat, CCTs and Flight teams have been turned away because they showed up clueless about needs of the patient they were called to transport and the teams have also refused a patient after contacting their medical director because the patient was unstable or it was something the just were not trained for. It seems those with the more experience and education can weigh the consequences more effectively and aren't inclined to think "we're the only ones" or from some other emotional argument.

Edited April 11, 2010 by VentMedic

[Kiwiology]

Here's an idea for both you an ERdoc...talk to a neonatalogist. See if a 25 week baby is viable.

Well I sure was, and we're talking the eighties here .... <tongue in cheek, ow my tongue>

I must wholeheartedly agree with VentMedic here, there is an inherent difference between being "able" to perform a skill from a medicolegal or licensing perspective and being able to actually perform that skill or procedure. I am certified to do things I have not done in years and would not want to be thrust into a situation of having to do them, simply because the cobwebs in the noggin are a wee bit too thick and it's a risk I don't want to take.

This case is a really good example of why the ambulance service here has divulged itself of high needs transfers simply because it's not something ambos have experience in. They may supply some wheels but Regional IFT and Neonate/Paediatric Intensive Care teams are used because they have the expertise to manage the patient that Paramedics do not.

Edited April 12, 2010 by kiwimedic

[ERDoc]

Vent, I won't speak for JP (he seems to be able to do that just fine) but I am well aware of our ability to save 23, 24, 25 week wheezers and seizers. I am not arguing the point of whether this baby was viable. My first comment to you was to provide a source for your statistics. If you are going to provide statistics to further your arguement the onus is on you to provide the reference. I am not saying your statistics are wrong, you just need to provide a reference. I think 95.2246% of the people on this site would agree. I appreciate the fact that you provided the link to the case in the FL database but since I do most of my posting at work, I do not have nearly enough time to read through the entire case (Only in the American legal system can someone create a document several hundred pages long and call it a brief). I am just a little confused as to who some of the players are, where they are and what their level of care is. Without that info it is hard for me to pass judgement. Now, if this kid was coding and he wasn't intubated in a timely fashion then the crew should be held accountable.

I am in no way comparing the education of a paramedic to that of a doctor. No, we do not rotate through the NICU but we do rotate through L&D.

This was a no win situation either way you cut it. I think it is pretty safe to assume that there is no way of doing adequate fetal monitoring in this ER. For all we know, this kids is having decels and needs to be sectioned immediately due to a lack of oxygen. So, while this kid is slowly dying, are we going to wait for a full transport team to be assembled and to come from an hour away, in effect doubling the time it will take for the kid to be sectioned? On the other hand we can have a medic unit respond and transport the mother to a hospital with the appropriate level of care in half the time. You asked, "if your patient required a Specialist OB consult, would you settle for a GP because the OB was busy? Would you feel you did right by your patient?" No, I would not want to talk to the GP, I need an OB and so does this kid. He does not need an ER doctor either, he needs an OB. I have no problems taking care of him should he decide it's time to come out but he should be with the person who is most appropriate for him, the OB and the perinatologist. The best way for him to get to them is to get in the ambulance and go, not sit in the ER where I can't do anything to help. No ER doc is going to section this woman. The only indication for an ER doc to perform a c/s is maternal demise. We are just going to sit there and watch the baby die. It sucks, but that is the way it is.

There is (or should be) a standard level of care when you call for a medic unit. When I call for a transfer I don't ask, "Is Bill on? He's not good with peds so I don't think I want him to do the transport." I know the pt needs medic level care and it is up to the state and the company that hires them to make the determination if that medic meets the appropriate training/education. If I call for a medic unit, I assume that they can intubate 0-120 year olds, if not they should not be in the field.

If time allows, I will try to pull up the case and read through it since it is hard to debate the specifics in this case without knowing the facts.

[chbare]

ERDoc, a serious question and no sarcasm intended; using much imagination and filling in the blank details, would you fault a paramedic for not wanting to take this patient?

Take care,

chbare.

[ERDoc]

ERDoc, a serious question and no sarcasm intended; using much imagination and filling in the blank details, would you fault a paramedic for not wanting to take this patient?

Take care,

chbare.

No sarcasm taken, chbare. I would not fault the medic for accepting the patient. As for the decision of where to go and what they did, I don't have enough info to answer that. I try to put myself back in my EMT shoes and think if what I would do. As an EMT I probably would have taken the transfer (though I admit, back then, I didn't know what I didn't know). I might have asked for an extra person in case the woman did deliver.

[ERDoc]

I tried to look through the Volusia County Clerk stuff and was unable to get anything. I could access the site and pull up the case but I could not view any of the files.

[akflightmedic]

I am not saying your statistics are wrong, you just need to provide a reference. I think 95.2246% of the people on this site would agree.

Nice responses...however I had to give 2 thumbs up for this gem.

[p3medic]

There are a lot of details of this case missing. Making some assumptions, it would seem that the sending and recieving docs felt the patient would make the transfer without delivering, or they would have planned for that eventuality. The EMS crew that arrived likely were assured of that as well. The sending doc must have felt this or would never have sent the woman with a crew of 2, a driver and a medic. With one medic in the back with 2 patients, I have a hard time faulting him/her for not intubating the kid. Securing an ETT in a 25 weeker in a moving truck is difficult at best, not to mention other resus that may need to take place. Even the most skilled neonatologist would be very stressed managing this kid solo in a moving ambulance. I have a hard time faulting the ambulance company for the outcome, I believe it is the sending/recieving docs who decide what level of transfer is appropriate.